Work Sample Detail Form

Step 1: Please submit a 20-minute segment of the audio recording that you would like to have coded by clicking the "Upload File(s)" button above. BE SURE TO INCLUDE YOUR NAME IN THE FILE NAME and wait until the file has been fully uploaded before submitting the form below. COMPRESSED MP3 files are much better, so CLICK HERE TO CONVERT YOUR FILE TO A SMALLER MP3. (A green box with the file name will appear when the upload is complete.)

Step 2: Please fill out and submit the form below. Before you submit it, you will attach a completed 2017 Work Sample Reflection Form using the "Choose File" button near the bottom of the page. If you have not yet downloaded the form, you can do so using the link.

Step 3: CLINICIAN CERTIFICATION OF CLIENT PERMISSION

By submitting this form you certify that you have obtained this audio-recorded work sample of a therapy session with the client’s permission and knowledge. You have placed a signed copy of the client’s written permission to tape this session in the client’s file in the agency where the recording was made.

Need help? Feel free to contact us at mint.tnt.coding.2017@gmail.com if you have questions or concerns about the uploading process.

Work Sample Form

* indicates required field

Applicant Name:*

Email:*

Date:*

Name of audio file:*

Language of the recorded sample:*

20-minute segment of the recording that you would like to have coded:*

This recording is:*

an actual patient/client encounter
a “real-play” addressing a real behavior change issue (this option only available in non-English languages)

Change Goal/target behavior (This target behavior will be used to assess change talk in the session and evaluate the appropriateness of MI for this interaction.):

You can attach your completed "2017 Work Sample Reflection Form" by clicking the "Choose File" button.

Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.

CAPTCHA Code:*

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